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Claim denials are a well-documented challenge for healthcare organizations. Denied claims take much longer to pay out than first-time claims, if they get paid at all. Each one means additional hours of rework and follow-up, pulling in extra resources as staff review payer policies and figure out what went wrong. It's time-consuming and costly. Beyond dollars and paperwork, denials affect patient care as uncertainty about payments leads to delays in treatment or unexpected out-of-pocket costs. But how do healthcare leaders feel about the state of claims management today? How are they tackling the administrative burden? Is there any light at the end of the denials tunnel?   Experian Health surveyed 210 healthcare revenue cycle leaders to find out. The 2024 State of Claims report breaks down the survey findings, including insights into how automated claims technology is being used (or not!) to optimize the claims process and bring in more revenue. What is the current denial rate for healthcare claims? 38% of survey respondents said that at least one in ten claims is denied. Some organizations see claims denied more than 15% of the time. That's a lot of rework and lost revenue that providers were counting on. In 2009, claims processing accounted for around $210 billion in “wasted” healthcare dollars in the US. A decade later, the bill had climbed to $265 billion. Industry reports—including Experian Health's State of Claims series—repeatedly observed a rise in denial rates. Today, 73% of providers agree that claim denials are increasing, while 67% feel it's taking longer to get paid. Providers constantly worry about who will pay – and when. What are the most common reasons for healthcare claim denials? According to the State of Claim survey respondents, the top three reasons for denials are missing or inaccurate data, authorizations, inaccurate or incomplete patient info. In short? The problem is bad data. Given how much information has to be processed and organized to fill out a single claim, this isn't surprising. From patient information to changing payer rules, the sheer volume of data points to be collated creates too many opportunities for errors and omissions. On top of that, the rules are always changing. More than three-quarters of providers say payer policy changes are occurring more frequently than in previous years, making it increasingly difficult to keep up. Other challenges, such as coding errors, staff shortages, missing coverage and late submissions still play a role, but it's clear that solving the data problem could make a meaningful dent in the denials problem. Read the blog: How data and analytics in healthcare can maximize revenue Could automation improve claim denial statistics? To help end the cycle of denials, more healthcare providers are turning to claims management software to resolve or prevent the snags that interfere with claims processing and billing workflows and boost claim success rates. That said, around half of providers still review claims manually. Despite the proven benefits of integrated workflows and automation, the drive to implement new technology during the pandemic seems to have lost momentum: the number of providers currently using some form of automation and/or artificial intelligence (AI) has dropped from 62% in 2022 to 31% in 2024. Could this be down to a lack of comfort with how new technologies work? Only 28% feel confident in their understanding of automation, machine learning and AI, compared to 68% in 2022. For those who are curious but cautious, here are a few ways claims automation can help improve claim denial statistics: Connect the entire claims process end-to-end: Using an automated, scalable claims management system like ClaimSource® helps providers manage the entire claims cycle in a single application. From importing claims files for faster processing to automatically formatting and submitting claims to payers, it simplifies the claims editing and submission process to boost productivity. Submit more accurate claims: 65% of survey respondents say submitting clean claims is more challenging now than before the pandemic. There's a strong case, then, for using an automated claim scrubbing tool to reduce errors. Claim Scrubber reviews pre-billed claims line by line so errors are caught and corrected before being submitted to the payer, resulting in fewer undercharges and denials and better use of staff time. Improve cash flow: Automating claim status monitoring is one way to accelerate claims processing and time to payment. Enhanced Claim Status eliminates manual follow-up so staff can process pended, returned-to-provider, denied, or zero-pay transactions as quickly as possible. Eliminate manual processes: While there are some tasks that genuinely need a human touch, too much staff time is wasted on repetitive, process-driven activities that would be better handled through automation. Denials Workflow Manager automates the denial process to eliminate the need for manual reviews. It helps staff identify denied claims that can be resubmitted and tracks the root causes of denials to identify trends and improve performance. It also integrates with ClaimSource, Enhanced Claim Status and Contract Manager, so staff can view claim and denial information on a single screen. Experian Health was client-rated #1 by Black Book™ '24 in Denial & Claims Management Outsourcing, Health Systems. Learn more Improving claim denial statistics with AI While automation speeds up the denials workflow by taking care of data entry, AI can look at that data and recommend next steps. Current ClaimSource users can now level up their entire claims management system with AI AdvantageTM, which interprets historical claims data and payer behavior to predict and prevent denials. The video below gives a handy walk-through of how AI Advantage's two offerings, Predict Denials and Denial Triage, can help providers respond to the growing challenge of denials: As the survey shows, there's a growing need for easy-to-implement solutions to the denials challenge. While progress has been made, the findings suggest there's still room to use automation and AI more to prevent denials and level the playing field with payers. Download Experian Health's 2024 State of Claims report for an inside look at the latest claim denial statistics and industry attitudes to claims and denials management. 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Reimbursement issues in the healthcare industry are complex, but reimbursement is essential for healthcare organizations. Proper reimbursement allows providers to run operations efficiently and deliver consistent, high-quality patient care. It also enables organizations to invest in technologies that advance their operations. Read on to learn more about the causes of reimbursement issues and discover the strategies, tools and automated solutions healthcare providers can use to address them. Understanding reimbursement issues in healthcare Healthcare organizations often provide care without upfront payment and hope that healthcare payers will fulfill their obligations and settle their bills. This system impacts all healthcare stakeholders and influences the quality and timeliness of patient care. It also affects staff productivity, satisfaction, hospital operational efficiency, cash flow and bottom line. However, the reimbursement system is also fraught with long-standing challenges that complicate financial growth for healthcare organizations. Claim denials, changing reimbursement landscape and payer rules, prior authorization hurdles and staffing shortages complicate reimbursement issues in healthcare and cost hospitals billions of dollars in administrative complexities. Key challenges of healthcare reimbursement concepts Key challenges that fuel reimbursement issues and impact hospital cash flow include: High patient volumes and submission of inaccurate claims Complex payer policies, compliance issues and poor communication in payer-provider partnerships Increasing claims denials leading to nonpayment Staff shortages and lack of training Slow adoption of data, analytics and automation solutions Causes of reimbursement issues By identifying the causes of reimbursement issues that result in delays and nonpayments, healthcare organizations can develop effective strategies to tackle them. Here is a closer look at why reimbursement issues commonly occur: Rising claim denials Claim denials lead to delayed or lost reimbursements, which amount to millions of dollars in lost revenue for hospitals. The Journal of AHIMA reports that claim denials cost hospitals $5 million, annually. According to Experian Health's State of Claims report, 38% of healthcare providers experience claims being denied 10% of the time, or more. 67% of respondents also agreed that reimbursement times are increasing. A report from the American Hospital Association noted that Medicare Advantage plan payment denials increased by 56% for the average health system between January 2022 and June 2023. These denials led to a 28% decline in cash reserves—even as maintenance expenses rose by 90% and other operational costs increased by up to 35%. With increasing claim denials, rising operational costs and a drop in cash reserves, revenue cycle leaders are under pressure to address costly claim denials. Staffing shortages and lack of appropriate training Challenges with staffing shortages and inadequately trained staff to handle revenue cycle management processes can lead to reimbursement issues for healthcare organizations. New research, published daily, shows that healthcare organizations are grappling with staffing shortages and the associated consequences. Experian Health's recent survey, Short Staffed for the Long-Term, identified staffing shortages as being strongly linked with increasing claims denial and declining reimbursement rates in healthcare. In fact, nearly all survey respondents noted that staff shortages have affected their organization's revenue opportunities. According to 70% of the survey respondents, staff shortages are seriously impeding payer reimbursement, and 83% report that it has become increasingly challenging to follow up on late payments or provide assistance to patients facing financial difficulties. In another Experian Health survey, The State of Patient Access, 2023: The Digital Front Door, 87% of providers report that healthcare staffing shortages are worsening healthcare access. Additionally, inadequate and lack of up-to-date training in handling medical coding, eligibility verification, patient estimates and other necessary administrative processes for preparing and submitting clean claims and receiving reimbursement hamper the efficiency of existing staff. Complex prior authorization process When healthcare organizations fail to obtain prior authorization in cases where it is needed, they can inadvertently face healthcare reimbursement issues. Prior authorization is a cost-control mechanism used by payers to confirm the justification for costly healthcare services. When prior authorization is required, providers must receive approval from payers before their services can be eligible for reimbursement. Prior authorization is a heavy and time-consuming administrative burden. According to the 2023 AMA prior authorization survey, every healthcare physician completes 43 prior authorizations per week on average—a process that takes about 12 hours. Worse, more than a quarter of providers report that prior authorizations are often or always denied. The complex prior authorization process leads to treatment delays, abandonment and reimbursement hassles. Many denials occur after patients have already started receiving care, or or when required care is only partially covered, causing further challenges. Changing reimbursement policies and payer rules Healthcare providers unintentionally fall behind in staying updated on critical reimbursement policies. The reasons vary, but typically include shifts in the reimbursement landscape, inconsistencies in payer rules, unannounced rule changes and poor communication in payer-provider relationships. Complex and ever-evolving payer policies also result in substantial losses for hospitals. Hospital revenue and resources, staff productivity and satisfaction and patient experience all bear the brunt. Hospitals relying on manual processes instead of automated software solutions to manage reimbursement hurdles are often hit even harder. Strategies to resolve healthcare reimbursement issues Organizations working to achieve impactful reimbursements can adopt strategies for success, including: Adopt AI and automation to prevent claim denials In the State of Claims 2024 report, only 31% of providers reported using some form of automation and/or AI technology. Automated solutions provide a time-and-resource-efficient approach for healthcare organizations to streamline claims and revenue cycle management. For example, ClaimSource® is a single software solution used to automate the claims management process and improve reimbursement rates. This solution automates tasks crucial to claims approval and reimbursements, like eligibility verification and coding, making the process faster and error-free. Experian Health's AI Advantage™ is a prime example of an AI-powered solution that works seamlessly with automation solutions to provide organizations with the greatest potential for reimbursement. It offers a two-in-one avenue relevant before claims submission and after claims denial. Organizations can reduce denial rates with Predictive Denials and predict high-value denials that improve reimbursement rates with Denials Triage. Implementing AI and automation can help strengthen financial performance and increase reimbursement rates for healthcare organizations. When integrated with AI-powered solutions that provide prediction and accuracy, automation takes the claims management burden off the shoulders of overworked staff. Staff can then redirect their efforts towards activities that enhance patient experience, care quality and outcomes. Automate prior authorizations Prior authorizations can be time-consuming and expensive, especially with manual, error-prone systems. According to a paper published in the Journal of Perspectives in Health Information Management, 85% of providers consider the burden associated with prior authorization to be “high or extremely high.” Yet, many providers still rely on manual processes, which further complicate prior authorizations and create stumbling blocks to getting reimbursements. Instead, healthcare organizations can embrace automated solutions, like Experian Health's Prior Authorizations solution, to streamline this process. This solution automates the prior authorization inquiry and submission process and helps providers achieve prompt payments, ultimately ensuring predictable revenue cycles. By adopting automation, they save staff time and improve operational efficiency, which also improves care delivery and elevates the patient care experience. Equip staff with technology solutions Healthcare billing teams can also effectively tackle critical aspects that increase the potential of securing reimbursements using technology solutions designed to help boost productivity without increasing headcount. These include: Denial Workflow Manager to eliminate the need for manual review of claims status and remittance advice, resulting in reduced denials Enhanced Claim Status eliminates manual follow-up tasks and lets providers respond early and accurately to pended, returned-to-provider, denied, or zero-pay transactions before the Electronic Remittance Advice and Explanation of Benefits are processed Patient Payment Estimates to provide better price transparency so patients are empowered to make better decisions and healthcare providers get paid faster Overcoming reimbursement issues for better healthcare outcomes Reimbursement issues pose many challenges for today's healthcare organizations. They burden hospitals with excessive administrative work, cause delays in healthcare delivery and put the patient experience in the backseat. They also impact healthcare provider satisfaction and productivity and worsen hospital financial performance. Empowering staff with automated solutions enables them to swiftly and accurately manage the different fragments leading to reimbursement. This can result in improved healthcare outcomes and organizational profitability. Learn more about how Experian Health's Claims Management and Clearinghouse solutions (ranked #1 Best in KLAS 2024) can help organizations secure reimbursements that boost their bottom lines. Get reimbursed faster Contact us

Despite increased access to claims management technology, claims denials are still on the rise in 2024. Contributing factors include growing healthcare costs, stricter payer reimbursement policies, and claims processing errors. Providers are seeing an uptick in nonpayment, plus an added burden on administrative staff, disrupted patient care, and hits to the bottom line. Experian Health surveyed over 200 healthcare professionals, primarily in executive or management roles, to better understand the current state of claims. The findings of the State of Claims 2024 report break down the latest health insurance claim denial statistics, reasons for denials, and providers' concerns about reimbursement. Rising healthcare costs: who will foot the bill? The U.S. healthcare system is the most expensive in the world, and costs continue to rise. In 2022, healthcare spending reached $4.5 trillion, a threefold increase from $1.4 trillion in 2000. In 2023, costs rose 7.5% to $4.8 trillion. Paying for healthcare is becoming more and more out of reach for patients and causing great concern. Over three-quarters (77%) of providers worry patients will skip out on their medical bills. Payer reimbursement challenges are also weighing heavily on healthcare leaders' minds. More than 75% are worried about nonpayment due to ever-evolving payer policy changes. They also have concerns about the pre-authorization struggles that have continued since 2022, as reported in the State of Claims 2022 survey. Hospitals are particularly feeling the financial pinch of operating within such an expensive environment and face uncertainties about meeting financial obligations on top of other major post-pandemic challenges like staff shortages. The impact of claims denials Providers continue to see claims being denied in greater numbers. In 2022, 42% of respondents said denials are increasing. The number jumped to 77% in 2024. Similarly, the time it takes to be reimbursed is increasing, per 67% of respondents. That number was 51% in 2022. In 2024, 84% of healthcare organizations will make reducing denied claims a top priority. The Journal of Managed Care & Specialty Pharmacy reports that the burden of denied claims totals around $260 billion annually. The impact of claim denials is far-reaching, affecting the patient experience and revenue cycles. Struggles with claims also burden staff and drain resources, contributing to even more losses. The growing challenge of data collection, verification and authorization Successful claims processing depends on accuracy. However, achieving accuracy in data collection, verification, and authorization processes remains a continued challenge for claims management teams. Nearly half of respondents (46%) in the State of Claims 2024 report identified missing or inaccurate information as the primary cause for denial. Inaccurate or missing data also creates extra steps in claims processing, resulting in the need for secondary checks and “wasted” healthcare dollars. Survey respondents reported using multiple solutions to collect all the necessary patient data for claims, with some using as many as four different products. Leveling the playing field in claims management with technology Staying on top of reimbursement requirements and processes is complex, resource-demanding and time-consuming. Inaccuracies commonplace with manual processing exacerbate issues and further extend processing and reimbursement times. However, automation and AI technology have proven effective at reducing claims denials and the burden of manual processing. “Adding AI in claims processing cuts down denials significantly,” Tom Bonner, Principal Product Manager at Experian Health, explains. AI automation quickly flags errors, allowing claims editing before payer submission. It's not science fiction—AI is the tool hospitals need for better healthcare claims denial prevention and management.” During the pandemic, providers embraced new technology to meet immediate needs; however, that momentum slowed in recent years. In 2022, survey data revealed that 62% of providers were using some form of automation and AI technology. Yet, in 2024, only 31% said they used this type of technology. Here's how claims automation can help healthcare organizations improve claims success rates: Manage the entire claims process: Using an automated, scalable claims management system, like ClaimSource®, helps reduce denials and increase revenue. Providers can manage their entire claims cycle in a single application and ensure claims are clean before submission. Submit more accurate claims: An automated claims submission tool, like ClaimScrubber, helps identify errors that typically result in denials or underpayments before submission. This results in quicker payments, less time chasing aged accounts receivables, and improved cash flow. Eliminate manual processes: Providers that use Denials Workflow Manager can target claims that need attention immediately, managing denials more effectively and increasing reimbursements significantly. Improve cash flow: Enhanced Claim Status helps providers take an early-and-often approach to monitoring claim status in the adjudication process. It eliminates manual follow-up tasks, allowing providers to respond early and accurately to pended, returned-to-provider, denied or zero-pay transactions. Prevent denials: Experian Health's AI Advantage™, an AI-driven platform, uses an organization's own historical claims data, plus Experian Health's sophisticated knowledge of payer rules, to continuously learn and adapt to an ever-changing payer policy landscape. This technology helps providers better predict and prevent claims denials, focus on high-priority claims, and boost overall revenue. Adaptation of technology is likely on the rise with 45% of healthcare leaders planning to invest in automation in the next six months. Over the next year, these investments could pay off if claims denials start to decrease as a result, prompting more healthcare organizations to boost investments in claims management technology. Download the State of Claims 2024 report to get the latest health insurance claim denial statistics, or contact us to learn how Experian Health can help with better claims management. Get the report Claims management solutions

Millions of healthcare claims are denied annually, costing providers billions in lost revenue and expensive appeals. A 2024 survey shows that around 15% of all claims submitted to private payers, Medicare Advantage and Medicaid managed care plans are initially denied. Since most involve charges of $14,000 and above, the stakes are worryingly high. Frustratingly, more than half of these denials are eventually overturned, but not before providers have spent an average of $43.84 reworking each claim. With hospitals and health systems spending almost $20 billion on denial management in 2022 alone, this administrative tug-of-war with payers brings a substantial toll. While some denied claims are valid, there's no doubt that many are avoidable, as evidenced by the number that are successful on the second try. This is where effective claim denial management strategies and solutions come into play. Understanding the root cause of denials in healthcare and implementing the right systems ensures that claims are right the first time. This article looks at the importance of denial management, strategies for improvement, and why more providers are shifting from defense to offense by putting automation and artificial intelligence (AI) at the heart of their claims management processes. The importance of denial management in healthcare A traditional denial management definition in healthcare might focus on the steps needed to resolve denials after they occur. The reality is much broader. Providers need a proactive strategy that addresses why claims are denied in the first place to prevent them from occurring in the future. Claims may be denied because the insurer doesn't consider the treatment medically necessary, believes there's a cheaper alternative available or doesn't cover it because the patient's insurance doesn't cover it. Sometimes, the culprit is an erroneous billing code or typo. Providers avoid costly and time-consuming rework by ensuring that claims are accurate, compliant, and complete at the start. As denials become more common and costly, streamlining denial management is increasingly urgent. The provider-payer relationship One of the major challenges for providers is the shifting relationship with payers. According to a survey by the American Hospital Association (AHA), 78% of hospitals say interactions with commercial payers are getting worse, with 84% noting the rising costs of complying with insurer policies. Providers report spending more time on prior authorizations, yet the growing pile of denials includes pre-authorized services. The pattern of claims being denied and then granted on appeal drains financial resources, delays patient care and contributes to staff burnout. Moreover, payers have been much faster in adopting AI-based technology, allowing them to process and deny claims at an unprecedented rate. Providers that rely on traditional denial management methods are starting to fall behind. The denial management process: how it works Healthcare denial management involves four key steps: Track all claims from submission through final adjudication and identify denials as quickly as possible. Denials should be categorized by type, payer and service to identify trends and understand underlying issues that need addressing. Investigate the cause of each denied claim, such as coding errors, missing documentation or non-adherence to payer guidelines. This stage often involves collaboration among billing teams, coders and clinicians to pinpoint what went wrong. Rework the claim by gathering missing data or documents and correcting errors before resubmitting the claim to the payer for reconsideration. This will also include monitoring the outcome to see if the appeal is successful. Prevent future denials through improvement measures such as staff training, updates to billing software, and ongoing payer policy reviews. A preventive approach ensures claims are managed without a hitch and keeps revenue flowing. Strategies for effective healthcare denial management Prevent denials upstream with accurate patient access Because so many denials originate early in the revenue cycle, patient access should be the first target in any denial reduction strategy. Experian Health's Patient Access Curator solution uses AI-powered data capture technology to collect and verify patient information in seconds. A single click checks eligibility verification, coordination of benefits (COB), Medicare Beneficiary Identifiers (MBI), coverage discovery and financial information to determine the patient's propensity to pay quickly and accurately. Staff no longer need to run multiple queries and can have confidence that their claims are built on the correct data. Watch the webinar to learn how Patient Access Curator shifts denial management upstream and propagates clean data throughout the revenue cycle. Process denials more efficiently with workflow automation A second strategy is to automate the denials workflow to alleviate the administrative burden on staff and expedite the appeals process. Denial Workflow Manager automatically identifies denials, holds, suspends, zero pays and appeal status so staff can follow up quickly, without the need for manual reviews. They'll have the time and intel to rework the denials that are most likely to be overturned, resulting in maximum cash flow. When used alongside ClaimSource®, they can do all this using standardized protocols with claim and denial information on the same screen. Denial Workflow Manager provides American National Standards Institute (ANSI) reason and payer codes and descriptions so staff know precisely why a claim was denied. Reports and responses can be forwarded to Health Information and Practice Management Systems to facilitate better coordination. The tool also provides advanced analytics to identify trends and inform tactics for further improvement. This significantly reduces the overall time and cost associated with managing denials. The future of denial management in healthcare While automation has lifted healthcare denial management out of inefficient manual processes, AI takes predicting and preventing denials a step further. AI AdvantageTM enhances the denial management toolkit with two new offerings: Predictive Denials uses the provider's own claims data from within ClaimSource to identify claims that are most likely to be denied, so staff can step in to take corrective action before submitting the claim. Denial Triage analyses and segments denials that do occur so staff can focus on reworking claims with the highest potential for reimbursement. With these tools, providers can eliminate guesswork, reduce denials and minimize financial losses. But it's not just about finding more innovative ways of working: payers have already made huge strides in using AI to deny claims at speed and scale. The future of denial management in healthcare will hinge on technology, and providers will need to adapt to keep up with the fierce competition. Find out more about Experian Health's Denial Management Solutions and see why they're top-rated by clients in the 2024 Black BookTM RCM User Survey. Denial Management Solutions Contact us

Maintaining a healthy cash flow is the only way to deliver quality patient care, invest in state-of-the-art technologies and keep daily operations running smoothly. But that's easier said than done: data errors, delayed payments, denials and staffing disruptions leave providers vulnerable to escalating admin costs and revenue leakage, with little left over to reinvest. By adopting a few key revenue cycle management (RCM) strategies, providers can sidestep these challenges and bring in more dollars. This guide summarizes five revenue cycle management best practices healthcare leaders should follow to optimize RCM workflows and promote financial stability. Key challenges in revenue cycle management Common issues that can get in the way of a healthy revenue flow include: Inaccurate patient data leading to coding errors, claim denials and billing delays Increasing numbers of denied claims generate costly rework and wasted time Payer compliance issues that are constantly changing and time-consuming to monitor Growing numbers of self-pay patients struggling to pay their bills Labor shortages increase pressure on staff and leave the door open to sub-par performance Inadequate data insights hindering management's ability to spot opportunities for improvement Rapid technological changes leave providers on the back foot if they fail to keep pace with new developments. The dream scenario would be to avoid all these potential obstacles before they do too much damage. In reality, providers will need to choose a few priority areas to troubleshoot. Check out this guide to choosing the right key performance indicators for your revenue cycle dashboard to ensure the effective implementation of RCM strategies. Revenue cycle management best practices What does a successful revenue cycle look like? For busy RCM leaders, deciding what to tackle first can be overwhelming. While there's no one-size-fits-all RCM strategy, there are a few key issues that all organizations must pay attention to. Here are five areas of best practice to factor in: 1. Streamline patient registration and insurance verification Accurate patient data is the number one factor in building a robust revenue cycle. It doesn't matter how efficient claims management and collections processes are if the data they use is flawed. Automated registration and verification tools reduce the chances of manual errors entering the system to ensure correct billing, reduce denials, and speed up reimbursement. One pitfall to watch out for is the fact that some digital tools still require staff to check multiple payer websites and data repositories to verify insurance eligibility. Experian Health's latest patient access solution, Patient Access Curator, avoids this by using AI-driven technology to collect and verify patient information with a single click. 2. Automate claims submission and management According to Experian Health's State of Claims 2022 report, 62% of providers feel they lack the necessary data and analytics to identify issues in claims submission processes. A similar number believe the absence of automation prevents improvement. The CAQH Index backs this up, with the latest estimates suggesting the healthcare industry could save $18.3 billion by switching to electronic transactions. As with patient intake, there's an opportunity to leverage automation in claims management to prevent errors and delays so the organization gets paid faster. Experian Health's claims management products—ranked #1 in 2024 surveys by both KLAS and Black Book—automate each step of the claims workflow so providers can submit clean claims quickly and cut the need for time-consuming manual work. 3. Optimize denials management and appeals with AI Despite best efforts, claims denials remain a burden for many RCM teams. However, proactively understanding and addressing the root causes can help keep denials under control. There's an opportunity to go a step beyond automation and see how artificial intelligence and machine learning can help combat the denials challenge. AI AdvantageTM evaluates individual claims in real time to flag those with a high likelihood of denials based on historical payment data, so staff can intervene quickly before submission. Denials are then triaged using advanced algorithms so staff can focus on reworking denials with the greatest chance of payment, rather than wasting time on those that are never going to be approved. Eric Eckhart, Director of Patient Financial Services at Community Medical Centers in California, says that since implementing AI Advantage, “Now I have almost a whole week a month of staff time back, and I can put that on other things. I can pull that back from outsourcing to other follow-up vendors and bring that in-house and save money. The savings have snowballed. That's really been the biggest financial impact.” Watch the webinar: Hear how Community Medical Centers and Schneck Medical Center are using AI AdvantageTM to prevent and triage denials. 4. Choose the right technology and tools for enhanced RCM The three previous revenue cycle management best practices emphasize the importance of selecting the right tools for the task. Two things to look out for when adopting a new RCM product are how well it integrates with existing tools and systems, and whether it offers meaningful insights to drive ongoing improvements. Experian Health's integrated RCM solutions are designed to fit together seamlessly, often allowing staff to view information from multiple workflows within the same dashboard. By bringing together metrics such as financial performance, billing efficiency and collections rates into one place, these tools help staff make strategic decisions about resource allocation and operational improvements. 5. Keep up with regulatory compliance Finally, ensuring compliance with regulatory requirements cannot be overlooked. The reputational and financial risks are too great. Regular training for staff on compliance issues and maintaining up-to-date knowledge of government and payer requirements will minimize the risk of penalties. Choosing RCM tools that automatically check for relevant updates can help providers stay current. Price transparency is a topical example. While the Hospital Price Transparency Rule is designed to help healthcare consumers understand healthcare costs and make more informed decisions about their care, implementation has proven tricky for providers. With the right technology and third-party support, it's much easier to stay compliant. Watch the webinar: See how Experian Health and Cleverley & Associates have partnered to help healthcare organizations navigate price transparency in 2024. Looking for more insights into revenue cycle management best practices? Contact Experian Health today to discover how our RCM solutions can transform your revenue cycle and increase cash flow year over year. Revenue cycle management solutions Contact us

Healthcare claim denials persist as a significant challenge, impacting the efficiency, affordability and timeliness of healthcare delivery and hospitals' financial well-being. They contribute a substantial portion of the staggering $265 billion annual in waste attributed to administrative complexities. On average, hospitals face a yearly loss of $5 million due to healthcare claim denials, amounting to 5% of their net patient revenue, according to the Journal of AHIMA. Yet it appears that the rise in claim denial rates continues unabated. Experian Health's State of Claims 2022 report revealed that 30% of respondents experience medical claims being denied in 10-15% of cases, and 42% confirm an increasing trend in denial rates from one year to the next. There is no question that the claims denial process is ripe for innovation, and that's where reducing healthcare claim denials with artificial intelligence (AI) comes in. Like many other sectors, healthcare providers are slowly but increasingly turning to automation and AI for more accurate data and better insights. The Experian Health survey shows over one-half of healthcare providers turn to AI-driven healthcare claims management software to reduce claim denials. "Adding AI in claims processing cuts denials significantly," Tom Bonner, Principal Product Manager at Experian Health, explains. AI automation quickly flags errors, allowing claims editing before payer submission. It's not science fiction—AI is the tool hospitals need for better healthcare claims denial prevention and management." The current challenges in claims management High patient volumes and complex payer policies Experian Health's 2022 State of Claims survey revealed that reducing denials was a top priority for almost three-quarters of healthcare leaders. Why? High patient volumes mean there are more claims to process, and changing payer policies and insurance coverage compound an already overwhelming problem. An Sg2 report predicts that patient volume issues will continue over the next decade, with inpatient hospital volumes growing by 2%. This rise in patient numbers will require more data for claims management processing. Hospitals, often short-staffed, will have to allocate more resources to ensure claim approval and increase efforts to address claims denial. In addition to managing increasing patient volumes, keeping track of changing payer coverage and requirements has always been challenging for providers. The inconsistency of these payer rules and communication problems exacerbate the situation. Healthcare providers may need efficient solutions to keep up with these rule changes or allocate more time and resources to addressing and revising claims. Labor shortages and financial pressures According to a data brief from the American Hospital Association, the increasing rate of clinician burnout, the enduring effects of COVID-19, and ongoing strains on the healthcare workforce are compelling hospitals to recognize and tackle chronic labor shortages. Notably, 80% of healthcare leaders acknowledge that chronic staffing shortages present significant risks for their organizations. Increasing denial rates is one way these risks manifest. As the State of Claims 2022 report confirms, 30% of respondents mentioned staffing shortages significantly contribute to healthcare claim denials. Additionally, Experian Health's recent survey, Short Staffed for the Long-Term, which investigated the impact of healthcare staffing shortages, found that 70% of respondents facing staff shortages also experienced increasing denial rates. Labor shortages mean fewer hands on deck to deal with the claims processing workload, while financial pressures on hospitals mean the stakes are higher than ever to solve the problem of claim denials. Limitations and costs of manual claims processes Health payers deny hospital systems about $260 billion worth of inpatient claims annually. According to Experian Health's survey, manual processing and a lack of automation are the primary reasons for these medical claim denials. The State of Claims 2022 report found that 61% of respondents do not automate claims submission and denial prevention processes, leaving them to rely on manually processing claims. However, manual claims management tools simply cannot keep up with the complexities and data-intensive nature of claims processing. When claims processes are handled manually, healthcare workers are burdened with cumbersome tasks that could have been automated, there is a higher risk of errors that lead to claims denial, and there'll be more need to dedicate extra time and effort to appeal denied claims. These intensive steps necessary for manual claims processing drain staff resources and create opportunities for money and time waste that are eventually detrimental to the hospital's financial circumstances. How AI and automation address healthcare claim denials Automation and AI can ease the pressure by processing more claims in less time. They give providers better insights into their claims and denial data so they can make evidence-based operational improvements. AI tools achieve this by using machine learning and natural language processing (NLP) to identify and learn from data patterns and synthesize huge data swathes to predict future outcomes. While AI is ideal for solving problems in a data-rich environment, automation in claims processing can complete rules-based, repetitive tasks with incredible speed and reliability that a person might not achieve. By using automation and AI in claims processing, healthcare providers can gain better insights into their claims and denial data, resulting in improved financial performance and greater efficiency. Tom Bonner says, "AI in healthcare claims processing maximizes the benefits of automation for better claims processing, better customer experiences and a better bottom line for healthcare providers." However, the pace of AI adoption is somewhat slower in healthcare due to legacy data management systems and data silos. As efforts to improve interoperability progress, providers will have more opportunities to deploy AI-based technology. This prediction is already evident in claims management, where executives are keeping an ear to the ground to learn of new use cases for reducing claim denials with AI to help maximize reimbursements. Key benefits of AI in healthcare claims management Healthcare claims management upgraded with the inception of AI-driven healthcare claims management software exponentially benefits claims management through its predictive, accuracy, and error-reduction capabilities. Predictive Analytics and Pattern Recognition: The benefits of AI in healthcare claims processing lie in the ability of AI-driven solutions to predict potential issues before they occur by analyzing claims and providing a probability of denial that allows the end user to intervene and determine the appropriate collection. AI can analyze patterns in historical claims data to predict future volumes and costs, so providers can plan accordingly without simply guessing at what’s to come. Error Reduction and Clean Claim Submissions: AI can also assist in identifying inaccurate claims and improve claims processing accuracy to ensure clean claim submission and efficient revenue cycle management. Case studies and real-world applications AI and automation in claims processing are helping healthcare providers overcome the challenges contributing to increasing claim denial rates. Experian Health's AI-driven and automation solutions, like AI Advantage™, enable clients to benefit from the full potential of AI and automation to minimize claim denials. How Community Medical Centers uses AI Advantage to predict and prevent healthcare claim denials Community Medical Centers (CMC), a non-profit health system in California, uses Experian Health's new solution, AI Advantage, which uses AI to prevent and reduce claim denials. Eric Eckhart, Director of Patient Financial Services, says they became early adopters to help staff keep up with the increasing rate of denials, which could no longer be managed through overtime alone. "We were looking for something technology-based to help us bring down denials and stay ahead of staff expenses. We're very happy with the results we're seeing now." AI Advantage reviews claims before they are submitted and alerts staff to any likely to be denied based on patterns in the organization's historical payment data and previous payer adjudication decisions. CMC finds this particularly useful for addressing two of the most common types of denials: those denied due to lack of prior authorization and those denied because the service is not covered. Billers need up-to-date knowledge of which services will and will not be covered, which is challenging with high staff turnover. AI Advantage eases the pressure by automatically detecting changes in how payers handle claims and flagging those at risk of denial so staff can intervene. This reduces the number of denials while facilitating more efficient use of staff time. Eckhart says that within six months of using AI Advantage, they saw 'missing prior authorization' denials decrease by 22% and 'service not covered' denials decrease by 18% without additional hires. Overall, he estimates that AI Advantage has helped his team save more than 30 hours a month in collector time: "Now I have almost a whole week a month of staff time back, and I can put that on other things. I can pull that back from outsourcing to other follow-up vendors and bring that in-house and save money. The savings have snowballed. That's really been the biggest financial impact." How Providence Health found $30M in coverage and reduced denial rates with automated eligibility checks Providence Health is a prominent health system with 56 hospitals and over 1,000 physician clinics, serving an annual patient volume of over 28 million. This magnitude of patient volume created greater issues with slow and manual payer eligibility processes and increased eligibility denials. Furthermore, in response to Epic's growing payer plan table, Providence Health sought an effective solution to merge and organize data on insurance plans, contracts, and reimbursement details and automate eligibility tracking within the system. Their search led them to Experian Health's Insurance Eligibility Verification solution. According to Emily Brown, Director of Operation Excellence, "Our search for a solution that seamlessly integrates with Epic led us to choose Experian as our preferred vendor, given their proven track record of working with Epic." Providence Health implemented Experian's Eligibility solution, including a Bad Plan Code Detection tool to catch coding errors before submission. The solution also allowed them to stay connected to over 900 payers and provide backup connectivity to over 300 additional payers for uninterrupted service. The solution's automated work queues also helped staff work more efficiently. Providence reduced denial rates, saving $18 million in potential denials in 5 months of implementing Experian's Eligibility solution. The tool also helped them find $30 million in coverage annually while reducing staff workload. How Schneck Medical Center prevents and triages denials with AI Advantage™ Schneck Medical Center delivers care to four counties in Indiana, supported by a team of over 1,000 employees, 125 volunteers, and close to 200 physicians. According to Skylar Earley, Director of Patient Financial Services, "The challenge we (Schneck Medical Center) sought to overcome by leveraging AI Advantage at our organization was just gaining more insight into how denials originate and what actions we can take to prevent those from happening." Schneck Medical Center collaborated with Experian Health to implement: AI Advantage™ — Predictive Denials and AI Advantage™ — Denial Triage. They aimed to use these tools to identify claims that were more likely to be denied so that the appropriate personnel could address them and clean them before sending them to payers. They also wanted to be able to identify and prioritize denials with the potential for revenue reimbursement that will impact their bottom lines. AI Advantage™ — Predictive Denials enabled team members to make informed and timely decisions before submitting claims. In the first six months of using the tool, Schneck achieved a 4.6% average monthly decrease in denials. The time spent on denials decreased by 4x, and flagged claims were resolved in 3–5 minutes rather than the previous 12–15 minutes per correction. With AI Advantage — Denial Triage, billers were able to redirect their effort on denials more likely to be reimbursed. This prioritization enables them to avoid wasting time on high-dollar claims that are unlikely to be paid. "We had no insight into whether we were performing value-added work when we followed up and worked denials. Now we see those percentages," says Skylar Earley, Director of Patient Financial Services Steps to implementing AI in claims management AI Advantage works in two stages in claims management, reducing claims denial and addressing denied claims to prioritize those with the best value for reimbursement. Stage One: Predictive Denials Stage one is Predictive Denials, which uses machine learning to look for patterns in payer adjudications and identify undocumented rules that could result in new denials. As demonstrated by CMC and Schneck Medical Center, this helps providers prevent denials before they occur. Stage Two: Denial Triage Stage two is Denial Triage, which comes into play when a claim has been denied. This component uses advanced algorithms to identify and segment denials based on their potential value so staff can focus on reworking the denials that will impact their bottom line. Enhancing revenue cycle management with AI Embracing integrated workflows uncovers novel applications for reducing healthcare claim denials with AI and automation. AI Advantage seamlessly works within ClaimSource®, which means staff can view data from multiple claims management tools in one place. These integrations amplify the benefits of each tool, giving healthcare providers better insights into their claims and denial data. With richer data, organizations will find new ways to leverage AI to increase efficiency, reduce costs and boost revenue. Key differentiators In addition to its AI solutions, Experian Health offers solutions that automate claims processing to facilitate claims management and increase efficiency. ClaimSource® helps providers manage the entire revenue cycle by creating custom work queues and automating reimbursement processing. This intelligent healthcare claims management software ensures clean claims before they're submitted, helping to optimize the revenue cycle. The software generates accurate adjudication reports within 24 to 72 hours to speed up reimbursement. ClaimSource ranked #1 in Best in KLAS 2024, for its success in helping providers submit complete and accurate claims. This tool prevents errors and helps prepare claims for processing. Because the claims are error-free, providers can optimize the reimbursement processes and get their money even faster. Another Experian Health solution, Enhanced Claim Status, improves cash flow by responding early and accurately to denied transactions. This solution gives healthcare providers a leg up on denied, pending, return-to-provider, and zero-pay transactions. The benefits include: Provides information on exactly why the claim was denied Speeds up the denials process Automates manual claims follow-ups Integrates with HIS/PMS or ClaimSource Automation frees up staff to focus on more complex claims Denials Workflow Manager integrates with the Enhanced Claim Status solution to help eliminate manual processes, allowing providers to optimize claims submission and maximize cash flow. Using AI and automated solutions to prevent healthcare claim denials There's no question that healthcare claims denials management is an unwieldy, time-consuming, and ever-changing process. Reimbursement is complex, but human error plays a large part in missed opportunities and lost revenue. The revenue cycle becomes seamless with AI and automation in healthcare claims management. Any healthcare provider seeking faster reimbursement and a better bottom line knows that improving claims management is critical to better cash flow. AI and automation-driven claims management software offers healthcare organizations a way to achieve these goals. Contact Experian Health today to prevent healthcare claim denials and improve your claims management process with AI Advantage and other denial management solutions.

In healthcare revenue cycle management (RCM), the mantra is clear: maximize revenue and minimize costs. It's more complex in practice, requiring RCM leaders to anticipate and adapt to whatever's around the corner. Following the latest revenue cycle management trends is vital, as economic turbulence and labor shortages demand flexibility and resilience. Competition from new players and changing consumer expectations call for constant updates to the latest technology. And currently, as electoral news cycles heat up ahead of the general election, attention is turning to potential policy changes and their implications for revenue cycle management. Keeping an eye on how the industry evolves will help RCM managers hold the course for financial stability and growth. Here are 12 revenue cycle management trends to watch: 1. Investment in managed RCM services Investment in managed RCM services has become an increasingly attractive option for RCM managers grappling with persistent workforce challenges and navigating the intricate landscape of payer policies. Outsourcing has become a strategic solution to address staffing shortages and limited resources. By partnering with vendors like Experian Health, healthcare organizations can get access to specialist expertise, datasets and automated technologies they'd be hard-pressed to develop in-house. For example, Collections Optimization Manager allows users to retain control and oversight of their collections processes but comes with real-time support from a dedicated Collections Optimization Consultant for a bespoke collections strategy built on data insights and industry knowledge. 2. Staff shortages and reimbursement model changes Staffing shortages are particularly problematic when they bump up against changing reimbursement models. Unfortunately, staffing shortages are still common in the future of revenue cycle management. In Experian Health's latest staffing survey, 69% of respondents believe that staffing will continue to be a problem in the future. More providers are moving to value-based care models, which have implications for claims submission processes and provider-payer relationships. High staff turnover leaves providers without the knowledge and expertise to handle more complex claims and billing processes. A tool like Contract Manager and Contract Analysis, recently awarded Best in KLAS for Contract Management, helps monitor and manage payer contracts to stay on top of terms and conditions, mitigate risk and maintain financial stability. 3. Workflow inefficiencies Another way to ease staffing pressures is to improve workflow efficiency. A recent Bain report found that 40% of clinicians reported a lack of effective workflows, while up to 70% had never tried automated workflow management. There's a missed opportunity here, as manual processes and communication bottlenecks seriously disrupt revenue cycle functions. Organizations that leverage more efficient ways of working will secure a competitive advantage as new demands and pressures arise. Reviewing key performance indicators is a good starting point for determining where to focus improvement efforts. 4. Technological advancements in RCM The ongoing evolution of artificial intelligence (AI) has profoundly impacted various sectors, and the realm of revenue cycle management is no exception. AI-based tools will continue to shape the future of revenue cycle management, and providers will have to implement these tools in order to keep up with the competition. Machine learning algorithms increase RCM efficiency and accuracy by automating routine tasks, while advanced tools like AI AdvantageTM analyze vast datasets to identify patterns and predict outcomes. AI Advantage transforms claims management by predicting claims that are most likely to be denied, and then triaging denials so staff can focus on those with the highest likelihood of reimbursement. Eric Eckhart, Director of Patient Financial Services at Community Medical Centers, says, “We were looking for something technology-based to help us reduce denials and stay ahead of staff expenses. We're very happy with the results we're seeing with AI Advantage.” 5. Technology integration The amount of data being collected, generated, processed and shared within healthcare organizations is skyrocketing. More data means greater capacity for personalized services, fewer gaps in care, and more streamlined RCM processes—but only if data systems talk to one another. Opting for a single integrated solution avoids the pitfalls of shoe-horning new tools into legacy systems. For example, Experian Health's acquisition of Wave HDC means organizations can now access a single tool to check multiple data sources at registration. Patient Access Curator uses AI to perform eligibility verification, coordination of benefits, coverage discovery and more, to help healthcare organizations accelerate registration and reduce claim denials. 6. Medical billing errors Whether a coding mistake or an accidental typo, billing errors cost providers dearly in lost revenue and time. Unfortunately, they're a growing risk as more patients show up with coverage from multiple payers and high deductibles. On the upside, organizations should see improvements with relatively little effort—assuming they deploy the right tools and strategies. Patient Access Curator, mentioned above, uses AI and robotic process automation to collect and verify the information needed to compile error-free claims with just a single click. Watch the webinar to find out more about how Patient Access Curator helps providers eliminate errors and reduce claim denials from the front end. 7. Patient-centric approaches A McKinsey report published in April 2024 highlighted a continuing trend in healthcare consumers' keenness to use digital products and services when accessing care. Experian Health's series of patient access surveys show a consistent desire for personalization, convenience, choice and compassion in patient access. These principles underpin Experian Health's approach to helping providers open their digital front door. Online self-scheduling, digital registration, and tailored patient outreach all improve patient satisfaction and engagement, subsequently bolstering revenue generation. 8. Financial clearance and diverse payment options One specific opportunity relating to the above point lies in offering a patient-centered financial experience. Financial clearance tools and flexible payment plans have gained prominence by making it easier for patients to understand and manage their financial obligations. Tools like Patient Financial Clearance automate presumptive charity screening to see if patients qualify for financial assistance programs, provide scripts to help staff deliver compassionate financial counseling, and calculate affordable monthly payments based on individual circumstances. Case study: Discover How UCHealth wrote off $26 million in charity care with Patient Financial Clearance. 9. Financial engagement and omnichannel platforms Patient collections are a growing challenge for providers. Patients similarly complain of unnecessary friction in the payment process: The State of Patient Access 2024 survey found that 72% of patients want more digital payment options digital methods. By providing a unified experience across online portals, mobile apps and point-of-service payments, providers can increase patient engagement with financial processes and accelerate collections. 10. Challenges specific to each revenue cycle segment Organizations are shifting away from uniform solutions for the entire revenue cycle and instead embracing tailored strategies that accommodate the unique requirements of various departments, services, and workflows. By harnessing advanced analytics and automation, providers gain insight into the nuanced challenges within revenue cycle management, enabling them to adopt the best tools. This approach ranges from customizing intake and billing processes on a departmental basis to automating claims processing tailored to different payers' specifications. 11. Customizable RCM solutions Just as patients want tailored solutions, so too do providers. Data analytics and AI advancements enable providers to develop claims management solutions that fit their unique mix of payers and patients. On a recent webinar, representatives of Eskenazi Health discussed their use of Patient Financial Advisor, and how Experian Health consultants helped their organization customize their setup and workflow. 12. The role of strategic partnerships Partnering with a vendor like Experian Health can be a transformative step for healthcare organizations seeking to optimize their operations and enhance patient care. With Experian Health's expertise in healthcare technology and data management, organizations gain access to a comprehensive suite of automated solutions tailored to their specific needs. This also ties in with the first item in this list: implementing new ways of working isn't always easy, but with a trusted vendor, providers can manage and accommodate revenue cycle management trends more confidently, efficiently, and cost-effectively. By partnering with Experian Health: Providence Health found $30million in coverage and reduced denial rates IU Health processed $632 million in claims transmissions The pace of change may be relentless, but with the right tools and support, RCM managers can stay one strategic step ahead and future-proof their revenue cycle for whatever surprises lie in store. Learn more about how Experian Health's revenue cycle management solutions can help providers keep up with revenue cycle management trends while maximizing revenue and minimizing costs.

As revenue cycle leaders continue to navigate an increasingly complex financial landscape, preventing healthcare claim denials remains the number one priority. Experian Health's State of Claims 2022 report found that 30% of respondents see claims denied 10-15% of the time, while 42% were seeing the rate of denials increase year over year. Denials in healthcare, which can be easily avoided, contribute significantly to the waste of healthcare funds. These denials cause providers to lose hundreds of billions of dollars in profits annually. This blog looks at the key questions providers should ask to get to the bottom of why healthcare claims get denied, how to prevent healthcare claim denials and ways technology can support better denial management. Why do healthcare claims get denied? The State of Claims 2022 survey revealed that the most common causes of denied claims boil down to three issues: 1. Missing or incomplete prior authorizations Health insurers use prior authorizations to determine whether a patient's treatment is medically necessary and how much they can cover. Despite being introduced to encourage delivering high-quality, cost-effective care, the authorization process has become an intimidating administrative burden for healthcare providers. Even now, many healthcare providers rely on manual paperwork to execute an already complex and tedious authorization process. This outdated approach to authorization not only consumes time and money but also creates opportunities for missing or incomplete prior authorizations, increasing claims denial rates. Unsurprisingly, 48% identified missing or incomplete prior authorizations as one of the top three reasons for denials. 2. Failure to verify provider eligibility To be eligible for reimbursement, a provider must be a participant in the proposed Medicare or Medicaid program or other private health insurance plan. Eligibility verification involves confirming a patient's insurance information and that the planned services and provider are under their plan, which is critical for successful claims approval. Failure to verify provider eligibility may lead to claims denial if an out-of-network provider provides the services. Likewise, 42% of respondents said failure to verify provider eligibility was a common reason for denials. 3. Inaccurate medical coding Accuracy is the backbone of medical coding, another administrative task indispensable to claims approval. The slightest mistake when translating patients' diagnostic and treatment information into clinical codes can result in rejected claims. Unfortunately, providers are susceptible to coding errors due to the ever-changing coding rules, especially when they do it manually or work with unreliable automation solutions. They may work with outdated or incorrect codes, leading to claims denials. The State of Claims 2022 survey revealed similar shortcomings, with 42% of respondents stating that inaccurate medical coding led to denial. Other reasons for denied claims include: Incorrect modifiers Failure to meet submission deadlines Patient information inaccuracy Missing or inaccurate claim data Not enough staff to keep up Formulary changes Changing policies Procedure changes Improperly bundled services Service not covered 6 in 10 respondents said insufficient data and analytics made identifying and resolving issues with claims submissions difficult. A similar number said a lack of automation was hindering operational improvements. The good news is that these obstacles can all be effectively addressed with the right denial management strategy and digital tools. How do claim denials affect revenue cycles? Denials can be justified as necessary to prioritize spending on high-value care, but they have heavy consequences for hospitals' financial health. As highlighted in the Journal of Managed Care & Specialty Pharmacy, the weight of denied claims adds up to about $260 billion each year. This financial burden is pushed on hospitals, who may need to classify denied claims as debt, which, among other consequences of claims denial, ultimately disrupts their revenue cycles. The ripple effect of denied and underpaid claims on hospital revenue cycles also manifests in how delayed and non-payments restrict cash flow, hampering the provider's ability to operate efficiently and deliver care effectively. Significant staff time is lost to avoidable administrative activities and rework, as claims need to be corrected and resubmitted. This creates a bottleneck in the revenue cycle, which can lead to decreased revenue and additional costs. Extra work is particularly challenging for staff already under pressure due to ongoing labor shortages. For patients, denials can cause stress and confusion around how the cost of care will be met. How can providers reduce or prevent healthcare claim denials? Since most denials result from inaccuracies that originate early in the patient journey, the solution calls for better data management in patient access and robust checks just before claims are submitted. Reducing claims errors will contribute to better claim submission and higher reimbursement rates. Here's a step-by-step guide to improving healthcare claims processing: Utilize prior authorization software to automate the prior authorization process. This software-driven solution automates inquiries and submissions using updated and stored payer data, making the prior authorization process seamless and time-efficient and resulting in higher claim approval rates. Upgrade claims technology with tools such as ClaimSource®, which helps providers manage the entire claims cycle from one platform. By automating claims processing, ClaimSource helps ensure claims are clean before being submitted. The tool creates custom work queues so staff can prioritize high-value tasks and get paid faster. Improve the claims management process and prevent healthcare claim denials with AI Advantage™ — Predictive Denials and AI Advantage™ — Denial Triage. Predictive Denials flags claims that are more likely to be denied before they are submitted to the payer and tracks payer rule changes, reducing denial rates. Denial Triage prioritizes and segments denials most likely to be reimbursed, leading to increased revenue. Automate line-by-line claim reviews with Claim Scrubber to eliminate errors or omissions in claims before they are submitted. Claim Scrubber makes claims management operations more efficient, resulting in less rework, administrative costs, and delays. It can also be paired with Contract Manager, so providers can audit claims before and after remittance. Use an early-and-often approach to monitoring claim status and expedite reimbursement. Enhanced Claim Status eliminates manual follow-up and helps providers react quickly to any pending, returned-to-provider, denied, or zero-pay transactions, further improving cash flow. Experian Health's ClaimSource and Contract Manager solutions were both ranked number one in their respective categories in the 2024 Best in KLAS awards What is the best way to track and manage claim denials?  Most providers rely on manual and automated processes to manage claims and denials. Shifting from manual to digital can save time, reduce errors, and increase overall efficiency. However, providers may be wary of implementing new systems due to concerns about costs, data interoperability, and the staff learning curve. For this reason, it's essential to select a denials management solution that fits the provider's unique specifications. Denials Workflow Manager eliminates manual processes and allows providers to optimize the claims process according to the metrics that matter to them. It generates work lists based on the client's specifications, such as denial category and dollar amount, and incorporates extensive data analysis capabilities to identify the root causes of denials and improve upstream processes to prevent them. It can be easily implemented as a standalone product or integrated with ClaimSource to give users access to the entire claims and denial management cycle on a single screen. Staff training on claims management The State of Claims 2022 report revealed that 46% of respondents admitted that lack of staff training was an operational challenge contributing to claims denial. Training healthcare staff in managing and preventing claim denials is one of the most worthy investments to reduce the rate of claim denials. Hospitals can provide healthcare staff with adequate ongoing training on the granular details of claims processes before and after submission and access to automated claims management solutions. Healthcare staff should also be kept up-to-date on the latest tools and strategies on denial prevention and payer rules for claims submissions to ensure payment receipt after claim submission. Engaging patients in the claims process Though patients are usually not responsible for submitting claims to payers, they are an equal third party in the claims process and can be empowered to actively participate in every stage, from submission to approval and paying copays or deductibles. Effective patient engagement can be achieved by providing patients with an accessible, all-inclusive platform to register, review, and update information related to their care and benefit plan and communicate with healthcare staff as needed. Collaborating with payers to reduce denials The quality of collaboration between payers and providers affects the seamlessness and efficiency of the claims process. Therefore, it is crucial for providers to collaborate effectively with payers, especially given the constant changes in payer policies, to ensure that they stay up-to-date with and comply with the payer claims submission requirements. In cases of claim denials, they can also manage them effectively. By working together, payers and providers can also quickly resolve denial issues, ultimately improving system efficiency. Adopting automation and AI to prevent healthcare claim denials As one of the most complex institutions today, the healthcare industry has always grappled with a critical shortage of healthcare workers, staff burnout, and wasteful medical care spending, which costs $600 billion annually in the US. Despite the potential benefits of automation and artificial intelligence (AI) to ease these burdens and save about $200 billion to $360 billion annually in healthcare spending, their adoption has been lagging and met with resistance. However, more and more healthcare stakeholders are realizing that these technologies are a principal partner in making the healthcare system more efficient, simplifying and streamlining deeply complex processes, such as claims processing. For example, Experian Health's Patient Access Curator, an AI—and robotic process automation (RPA)-driven solution that enables eligibility and coverage verification and more accurate and submission-ready claims. By performing these tasks in seconds, all in one click, Patient Access Curator has helped clients save over $1 billion in denied claims since 2020, significantly boosting their bottom lines. Another example of efficient claims technology is ClaimSource. This all-in-one claim cycle management platform, powered by automation, transmitted $632 million in claims within five days and processed $1.1 billion of claims backlog for IU Health. AI Advantage™, Experian Health's revolutionary claims management solution that offers a two-pronged approach to preventing and managing denials: AI Advantage – Predictive Denials identifies claims that are at risk of being denied, so corrections can be made before claims are sent to payers. AI Advantage – Denial Triage comes into play post-submission, reviewing patterns in denials to prioritize those with the greatest likelihood of reimbursement. Given the volume, complexity and financial impact of the current claims workload, automation and AI are critical elements in the denials management toolkit. In the State of Claims survey, more than half of respondents said they were using automated claims processing, with many using automation to keep track of payer policy changes, automate patient portal claims reviews and digitize patient registration. Despite much media furor, AI is still the domain of early adopters: only 11% of respondents said they were using AI. But while automation can effectively eliminate unnecessary manual tasks, AI is a force multiplier for denials management, offering additional predictive capabilities and “learning” from historical data to prevent denials. Client feedback to date suggests that incorporating AI-powered denial management solutions could be a game-changer for providers looking to streamline operations, prevent lost revenue and free up capacity to focus on their primary mission of delivering quality patient care. Technology solutions for managing and preventing claim denials Efficiently managing the claims process and preventing or resolving claims denial requires robust and reliable technology solutions at every stage, especially in the complex and constantly changing world of claims management, where everything hinges on accuracy. These technology solutions can be responsible for heavy lifting many administrative tasks involved in the claims processes, from accurate data capturing during patient registration and prior authorization to submission to monitoring claim status and addressing claims submission outcomes. Hospitals can adopt claims technology, such as Experian Health's Patient Access Curator, for verifying insurance eligibility and coverage with real-time patient data correction or ClaimSource®, a single platform for monitoring and managing the claims cycle in one place. Find out more about how Experian Health helps healthcare providers prevent healthcare claim denials with automation and AI.

What do patients and providers really think about patient access services in 2024? Drawing insights from more than 1000 patients and 200 healthcare executives, Experian Health's fourth State of Patient Access survey pulls back the curtain. Previous surveys revealed a persistent gap between patient and provider perspectives on patient access, but could the gap finally be closing? The State of Patient Access 2024 report suggests that while discrepancies remain, the two groups appear closer than ever. This article provides a summary of the State of Patient Access 2024 report, and gives a run-down of patient and provider perspectives on patient access, what they see as top challenges, where opinions diverge and the steps providers can take to continue building a positive patient access experience in the year ahead. How do patients feel about patient access? 1. More patients think access has improved compared to last year 28% of patients believe patient access has improved over the last year, which is up from just 17% in 2023. As in previous years, patients' perception of whether access has improved hinges on how quickly they can see their doctor. Anything providers can do to accelerate scheduling and registration will be a winner. 2. Patients welcome the efficiency and accuracy of digital tools Patients have noticed improvements in scheduling and registration processes. They welcome the ability to book appointments anytime and avoid unnecessary paperwork using digital technology. That said, financial considerations trump convenience: the ability to look up insurance coverage and obtain accurate price estimates before care have risen to the top of the list of what patients consider the most important aspects to improve. 3. Cost of care remains a concern Unfortunately, patient sentiment around healthcare payments has remained relatively flat since 2022. Slightly more patients are receiving upfront cost estimates compared to previous years, but accuracy appears to have dropped, with 74% of patients reporting accurate estimates compared to 78% in 2023. Patients must have faith in their estimates if they are to plan for upcoming bills with confidence, and providers should be able to provide transparent and accurate payment estimates. What do providers think about patient access? 1. Providers are again more optimistic about improvements than patients Like patients, providers are generally positive about the state of patient access, though they may be a little too optimistic about the effect of improvement efforts. Around twice as many providers think access is better than the previous year compared to patients (55% compared to 28%). For providers, perceptions of improvements in patient access are closely tied to the impact of staffing levels. 2. Self-scheduling is back in favor Providers are aligned with patients on the need for digital scheduling and registration options. Interestingly, after the urgency to implement contactless scheduling during the pandemic began to wane in 2022, the latest survey suggests that self-scheduling is back in fashion, with 63% offering self-scheduling compared to 40% in 2022. 3. “Dirty data” remains a stubborn challenge Data collection at patient intake is a persistent headache for providers. Almost half (49%) say that inaccurate patient information contributes to claim denials. Improving the speed and accuracy of resolving patient information prior to claims submission were frequently listed in providers' top three challenges. See how healthcare organizations are using AI AdvantageTM to improve data accuracy and reduce claim denials. Digital technology bridges the gap between patient and provider perspectives on patient access When asked for their top three priorities for improvement, both groups ranked accurate price estimates and efficient insurance verification among their top two. While they diverge on the third – access to online health management tools for patients, and automated pre-authorizations for providers – it's interesting to note that these both reflect a desire to use digital solutions for greater efficiency and convenience. The survey highlights several opportunities to use digital technology to address upcoming challenges and continue to close the gap. Key challenges in patient access in the year ahead 1. Improving accuracy of upfront price estimates The survey showed 79% of providers plan to invest in patient access improvements soon. Given shared concerns about patients' ability to cover the cost of care, and worrying hints that some may postpone care due to cost concerns, prioritizing and providing accurate patient estimates would be a smart choice. While patients and providers are in closer agreement that estimates are accurate most or all of the time (74% and 85% respectively), there's clearly room for improvement. 2. Accelerating insurance verification and claims submission processes Several of the providers' top challenges speak to how difficult it can be to collate accurate information prior to claims submission. The need for better insurance reviews, more efficient management of prior authorizations, and more accurate patient information all contribute to the overarching goal of getting properly reimbursed. Almost a fifth say that managing multiple tools to determine eligibility, coordination of benefits (COB), and other pre-service checks is a top challenge. Could a single solution be the answer? Experian Health's new Patient Access Curator solution checks eligibility, COB, Medicare and commercial coverage, demographics and financial status in less than 30 seconds. Staff can check off several of these tedious tasks with just a single click. 3. Bolstering workforce capacity with technology A final challenge in the year ahead is the ongoing impact of staffing shortages. For the of providers who feel that staffing levels are disrupting delivery of scheduling and registration services, technology may offer a way through. Automation and artificial intelligence not only reduce the burden on staff by eliminating time-consuming manual tasks, but also allow staff to work smarter and faster on remaining tasks by improving data accuracy and insights. Most importantly, digital technology can improve scheduling, registration and payment processes for patients – and bring the patient experience in line with what both groups aspire to see. Download the full report: State of Patient Access 2024, or contact Experian Health to learn how technology can help streamline patient access.